63. A client, who is gravida 1, para 0, is admitted with a diagnosis of severe preeclampsia. A nurse starts the client on intravenous magnesium sulfate. For which expected side effect should the nurse closely observe the client?
63. A client, who is gravida 1, para 0, is admitted with a diagnosis of severe preeclampsia. A nurse starts the client on intravenous magnesium sulfate. For which expected side effect should the nurse closely observe the client?
. Decreased urinary output.
. Hypersomnolence.
. Absence of knee jerk reflex.
. Decreased respiratory rate.
Test-Taking Tip
This question is asking for the expected side effect of magnesium sulfate administration. Eliminate the answers that are indicative of magnesium toxicity.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Expected Effects/Outcomes
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Answer 1 is incorrect because decreased urinary output is not an expected side effect of magnesium sulfate; it is an indicator of worsening preeclampsia. Answer 2 is correct because hypersomnolence (excessive sleepiness) is an expected side effect not associated with magnesium toxicity, an unexpected side effect related to a high serum level. Answer 3 is incorrect because the absence of knee jerk reflex is a symptom of magnesium toxicity. Answer 4 is incorrect because decreased respiratory rate is a symptom of magnesium toxicity.